Pneumonia

Pathophysiology and Etiology

• The organism gains access to the lungs through aspiration of oropharyngeal contents, by inhalation of respiratory secretions from infected individuals, by way of the bloodstream, or from direct spread to the lungs as a result of surgery or trauma.
• Patients with bacterial pneumonia may have an underlying disease that impairs host defense; pneumonia arises from endogenous flora of the person whose resistance has been altered, or from aspiration of oropharyngeal secretions.
  • Immunocompromised patients include those receiving corticosteroids or immunosuppressants, those with cancer, those being treated with chemotherapy or radiotherapy, those undergoing organ transplantation, alcoholics, I.V. drug abusers, and those with HIV disease and acquired immunodeficiency syndrome.
  • These people have an increased risk of developing overwhelming infection. Infectious agents include aerobic and anaerobic gram-negative bacilli; Staphylococcus; Nocardia; fungi; Candida; viruses, such as cytomegalovirus; Pneumocystis carinii (also known as P. jiroveci); reactivation of tuberculosis (TB); and others.
• When bacterial pneumonia occurs in a healthy person, there is usually a history of preceding viral illness.
• Other predisposing factors include conditions interfering with normal drainage of the lung, such as tumor, general anesthesia, and postoperative immobility; depression of the central nervous system (CNS) from drugs, neurologic disorders, or other conditions, such as alcoholism, and intubation or respiratory instrumentation.
• Pneumonia may be divided into three groups:
  • Community acquired, due to a number of organisms, including Streptococcus pneumoniae
  • Hospital or nursing home acquired (nosocomial), due primarily to gram-negative bacilli and staphylococci
  • Pneumonia in the immunocompromised person
• People over age 65 have a high mortality, even with appropriate antimicrobial therapy.

NURSING ALERT

Recurring pneumonia commonly indicates underlying disease, such as cancer of the lung, multiple myeloma, or COPD.

Clinical Manifestations

For most common forms of bacterial pneumonia:

• Sudden onset; shaking chill; rapidly rising fever of 101° F to 105° F (38.3° C to 40.5° C).
• Cough productive of purulent sputum.
• Pleuritic chest pain aggravated by respiration/coughing
• Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use of accessory muscles of respiration, fatigue
• Rapid, bounding pulse

Diagnostic Evaluation

• Chest X-ray shows presence/extent of pulmonary disease, typically consolidation.
• Gram stain and culture and sensitivity tests of sputum—may indicate offending organism.
• Blood culture detects bacteremia (bloodstream invasion) occurring with bacterial pneumonia.
• Immunologic test detects microbial antigens in serum, sputum, and urine.

Management

• Antimicrobial therapy- depends on laboratory identification of causative organism and sensitivity to specific antimicrobials, or presumptive therapy with broad spectrum agent in milder cases.
• Oxygen therapy if patient has inadequate gas exchange

Complications

• Pleural effusion.
• Sustained hypotension and shock, especially in gram-negative bacterial disease, particularly in elderly patients.
• Superinfection: pericarditis, bacteremia, and meningitis.
• Delirium- this is considered a medical emergency.
• Atelectasis- due to mucous plugs.
• Delayed resolution.

Nursing Assessment

• Take a careful history to help establish etiologic diagnosis.
  • History of recent respiratory illness including mode of onset
  • Presence of purulent sputum, increased amount of sputum, fever, chills, chest pain, dyspnea, tachypnea
  • Any family illness
  • Medications, alcohol, tobacco, or I.V. drug use
• Observe for anxious, flushed appearance, shallow respirations, splinting of affected side, confusion, disorientation.
• Auscultate for crackles overlying affected region, and for bronchial breath sounds when consolidation (filling of airspaces with exudate) is present.

Nursing Diagnoses

• Impaired Gas Exchange related to decreased ventilation secondary to inflammation and infection involving distal airspaces
• Ineffective Airway Clearance related to excessive tracheobronchial secretions
• Acute Pain related to inflammatory process and dyspnea
• Risk for Injury secondary to complications

Nursing Interventions

Improving Gas Exchange

• Observe for cyanosis, dyspnea, hypoxia, and confusion, indicating worsening condition.
• Follow ABG levels/Sao₂ to determine oxygen need and response to oxygen therapy.
• Administer oxygen at concentration to maintain Pao₂ at acceptable level. Hypoxemia may be encountered because of abnormal ventilation-perfusion ratios in affected lung segments.
• Avoid high concentrations of oxygen in patients with COPD, particularly with evidence of CO₂ retention; use of high oxygen concentrations may worsen alveolar ventilation by depressing the patient's only remaining ventilatory drive. If high concentrations of oxygen are given, monitor alertness and Pao₂ and Paco₂ levels for signs of CO₂ retention.
• Place patient in an upright position to obtain greater lung expansion and improve aeration. Frequent turning and increased activity (up in chair, ambulate as tolerated) should be employed.

Enhancing Airway Clearance

• Obtain freshly expectorated sputum for gram stain and culture, preferably early morning specimen as directed. Instruct the patient as follows:
  • Rinse mouth with water to minimize contamination by normal flora.
  • Breathe deeply several times.
  • Cough deeply and expectorate raised sputum into sterile container.
• Encourage patient to cough; retained secretions interfere with gas exchange. Suction as necessary.
• Encourage increased fluid intake, unless contraindicated, to thin mucus and promote expectoration and replace fluid losses caused by fever, diaphoresis, dehydration, and dyspnea.
• Humidify air or oxygen therapy to loosen secretions and improve ventilation.
• Employ chest wall percussion and postural drainage when appropriate to loosen and mobilize secretions.
• Auscultate the chest for crackles and rhonchi.
• Administer cough suppressants when coughing is nonproductive only if there is no evidence of retained secretions.
• Mobilize patient to improve secretion clearance and reduce risk of atelectasis and worsening pneumonia.

Relieving Pleuritic Pain

• Place in a comfortable position (semi-Fowler's) for resting and breathing; encourage frequent change of position to prevent pooling of secretions in lungs.
• Demonstrate how to splint the chest while coughing.
• Avoid suppressing a productive cough.
• Administer prescribed analgesic agent to relieve pain. Avoid opioids in patients with a history of COPD.
• Apply heat and/or cold to chest as prescribed.
• Assist with intercostal nerve block for pain relief.
• Encourage modified bed rest during febrile period.
• Watch for abdominal distention or ileus, which may be due to swallowing of air during intervals of severe dyspnea. Insert a nasogastric (NG) or rectal tube as directed.

GERONTOLOGIC ALERT

Sedatives, opioids, and cough suppressants should be used cautiously in elderly patients, because of their tendency to suppress cough and gag reflexes and respiratory drive. Also, provide or encourage frequent oral care for pneumonia prevention.

Monitoring for Complications

• Remember that fatal complications may develop during the early period of antimicrobial treatment.
• Monitor temperature, pulse, respiration, blood pressure, and oximetry at regular intervals to assess the patient's response to therapy.
• Auscultate lungs and heart. Heart murmurs or friction rub may indicate acute bacterial endocarditis, pericarditis, or myocarditis.
• Employ special nursing surveillance for patients with:
  • Alcoholism, COPD, immunosuppression- these people as well as elderly patients, may have little or no fever.
  • Chronic bronchitis- it is difficult to detect subtle changes in condition, because the patient may have seriously compromised pulmonary function.
  • Epilepsy- pneumonia may result from aspiration after a seizure.
  • Delirium—may be caused by hypoxia, meningitis, delirium tremens of alcoholism.
• Assess these patients for unusual behavior, alterations in mental status, stupor, and heart failure.
• Assess for resistant fever or return of fever, potentially indicating bacterial resistance to antibiotics.

NURSING ALERT

Delirium must be controlled to prevent exhaustion and cardiac failure. Prepare for lumbar puncture, if indicated, to rule out meningitis, which may be lethal. Mild sedation may be given.

Patient Education and Health Maintenance

• Advise patient that fatigue, weakness, and depression may be prolonged after pneumonia.
• Encourage chair rest after fever subsides; gradually increase activities to bring energy level back to preillness stage.
• Encourage breathing exercises to clear lungs and promote full expansion and function after the fever subsides.
• Explain that a chest X-ray is taken 4 to 6 weeks after recovery to evaluate lungs for clearing and detect any tumor or underlying cause.
• Advise smoking cessation. Cigarette smoke destroys tracheobronchial cilial action, which is the first line of defense of lungs; also irritates mucosa of bronchi and inhibits function of alveolar scavenger cells (macrophages).
• Advise the patient to keep up natural resistance with good nutrition, adequate rest. One episode of pneumonia may make the patient susceptible to recurring respiratory infections.
• Instruct patient to avoid fatigue, sudden extremes in temperature, and excessive alcohol intake, which lower resistance to pneumonia.
• Encourage yearly immunization for influenza and S. pneumoniae, a major cause of bacterial pneumonia.
• Advise avoidance of contact with people who have upper respiratory infections for several months after pneumonia resolves.
• Practice frequent handwashing, especially after contact with others.

Evaluation: Expected Outcomes

• Cyanosis and dyspnea reduced; ABG levels and Sao₂ improved
• Coughs effectively; absence of crackles
• Appears more comfortable; free of pain
• Fever controlled, no signs of resistant infection